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Therapeutic Psychological First Aid for
Front-line Healthcare Staff in a Pandemic
Julian D. Ford, Ph.D., University of Connecticut School of Medicine
Center for Trauma Recovery and Juvenile Justice
Center for the Treatment of Developmental Trauma Disorders
April 3, 2020
Overview
This webinar provides guidance to mental health and social work
clinicians who are conducting private sessions with front-line healthcare
workers who are caring for COVID-19 patients.
These are general principles and practice tips that are not intend to
prescribe specific practices and must be individualized for each unique
encounter and the therapeutic approach of each practitioner.
The single most important take home point is that every therapeutic
encounter with front-line staff must provide the worker with an
authentic affirmation of the value of their dedication and service, and a
sense of having learned something of value about themselves and how
they can actively find meaning or achieve a goal in the current crisis.
Doctors and nurses have worked around the clock to save the lives of those who have fallen ill with the coronavirus, like these huddling together to
operate on a critical patient in Wuhan.
Stressors Facing Front-line Healthcare
Responders Caring for COVID-19 Patients
WORKPLACE STRESSORS
“I’ve seen more death in 2 weeks than my 3 years as a resident”
✓Risk contracting COVID-19 virus from patients/co-workers
✓ Inadequate/unhygienic personal protective equipment (PPE)
✓ Insufficient staffing of MDs, nurses, respiratory therapists
✓ Inadequate/unavailable ventilators and ICU beds
✓ Inadequate/unavailable cleaning/disinfectant supplies
✓ Insufficient/unavailable vital drugs, medical or testing supplies
In this photo taken on Wednesday April 1, 2020, aid workers from the Spanish NGO Open Arms carry out coronavirus detection tests on
the elderly at a nursing home in Barcelona, Spain. (AP Photo/Santi Palacios) (Copyright 2020 The Associated Press. All rights reserved)
Stressors Facing Front-line Healthcare
Responders Caring for COVID-19 Patients“Nurses are working with tears in their eyes and the taste of
death in their mouth”
✓Extreme suffering and desperation of patients
✓Caring for and comforting frail elderly who are isolated
✓ Inconsolable family members unable to be with loved ones
✓Deaths of patients after days/weeks of heroic efforts
✓ Illness and uncertain recovery, or deaths, of co-workers
✓Never getting to know or communicate with dying patients
✓ Separation from and irritability with/from co-workers
Stressors Facing Front-line Healthcare
Responders Caring for COVID-19 Patients
WORKPLACE STRESSORS
“I expected families to hate me when I call for a 30-second check-in with them
every day with bad news, but all they say is ‘thank you, thank you, thank you!”
✓ Stigma from co-workers/public (“like we’re lepers”)
✓ Feeling unprepared for an always imminent surge catastrophe
✓ Feeling unprepared for moral dilemmas
✓Potential having to deny lifesaving treatment due to rationing
✓Potential choice between self-contamination and caring for patients
✓No break from constant demands, noise, use of PPE
✓ Insufficient support from administration/government
Nurses at Jacobi Medical Center in the Bronx gathered to protest a shortage of protective
equipment, including N95 masks.
Stressors Facing Front-line Healthcare
Responders Caring for COVID-19 PatientsHOME FRONT STRESSORS
“My family locked me out of our home, I feel totally isolated”
✓ Fear of contaminating children, spouse/partner, parents
✓ Forced separation from children/spouse for weeks at a time
✓ Inability to be with children/spouse due to work/exhaustion
✓Disconnection from friends and personal support system
✓Unable to eat well, exercise, sleep, maintain normal routines
✓Unable to share in childcare, and guilt for burdening others
This is the face of a front line
health care worker who just
spent 9 hours in personal
protective equipment moving
critically ill Covid19 patients
around London.
I feel broken - and we are
only at the start. I am
begging people, please
please do social distancing
and self isolation #covid19
Stressors Facing Front-line Healthcare
Responders Caring for COVID-19 PatientsMental Health Impact on Healthcare Responders
✓ Symptoms of depression and anxiety documented in JAMA
However COVID-19 healthcare workers are
experiencing acute traumatic stressors and losses
and should NOT be labeled with mental illness!
Acute Stress Reactions are expectable adaptations
NOT a disorder unless intrusions, hypervigilance,
numbing, or dissociation impair functioning
Stressors Facing Front-line Healthcare
Responders Caring for COVID-19 PatientsMental Health Impact on Healthcare Responders
More than Anxiety, Depression, or Acute Stress Disorder
1. Complex Trauma
Traumatic victimization + loss/unavailability of security
provided by emotional bonds in primary relationships
(usually associated with child abuse, rape trauma, domestic or
intimate partner violence, trafficking, torture, or genocide)
Stressors Facing Front-line Healthcare
Responders Caring for COVID-19 PatientsMental Health Impact on Healthcare Responders
More than Anxiety, Depression, or Acute Stress Disorder
2. Complex Bereavement
A combination of multiple traumatic separations and losses
Patients
Loved Ones
Familiar Way of Life
Future
When meeting with a healthcare or other
front-line staff during a crisis view this
session as an entire episode of care, but
also always offer whatever availability
you can feasibly provide for future
contact to provide a sense of continuity
and genuine caring.
Begin by introducing yourself and set
the frame: “Are you in a place where
you have privacy to talk freely, and
do you have any time constraints?
I’m here to listen and provide
support in any way that you feel is
helpful. How can I help?”
At the first opportunity, without interrupting,
add: “Whatever you share with me stays
between us except of course if we need to
take steps together to prevent a suicide or
child or elder abuse. You’re doing crucial
work to protect and take care of our patients
and colleagues, so this is an opportunity to
step back just briefly and take care of
yourself as well.”
Follow their spontaneous line of thought and
observe for nonverbal signs of emotion and
internal or external conflicts:
• In work role(s)–safety concerns (self,
colleagues, patients), fear of failure,
helplessness, loss, isolation, non-support
• In personal life–safety concerns (children,
partner, elders, significant others),
separation, helplessness, loss, isolation
Intervene judiciously, repeating 3 seamless steps: VCR
Validate their perspective + show respect for their dilemmas
Clarify long- and short-term goals based on their core values
Reframe highlighting strengths and what they already are
accomplishing (which they often cannot see or minimize)
Threats -> “Every patient is another death waiting to happen,
and now I’m bringing the virus home to my family. And if I
get sick I’ll be failing my duty and let my co-workers down.”
Reframe: courage, compassion, altruism, skill, caution,
dedication, perseverance, determination, honesty
Intervene judiciously, repeating 3 seamless steps: VCR
Validate their perspective + show respect for their dilemmas
Clarify long- and short-term goals based on their core values
Reframe highlighting strengths and what they already are
accomplishing (which they often cannot see or minimize)
Internal Experience and Emotion-> “I’m not afraid doing my
job, but I can’t relax because I know the time is coming when
PPEs will run out and the beds and ventilators will be full and
we’ll all go down and lose patients we could have saved.”
Reframe: alertness, awareness, being focused and proactive,
determination, dedication, courage, protectiveness
Intervene judiciously, repeating 3 seamless steps: VCR
Validate their perspective + show respect for their dilemmas
Clarify long- and short-term goals based on their core values
Reframe highlighting strengths and what they already are
accomplishing (which they often cannot see or minimize)
Coping -> “I never let up or stop doing everything I can for
each of my patients and to cover my team members’ backs,
but they say I take too many risks and worry about me. I
don’t let them see when I fall apart when I’m home alone.”
Reframe: dedication, immersion, integrity, self-awareness,
titrating the emotion impact, overcoming, being a role model
Close the session by summarizing the re-
frames to highlight what they have learned
about themselves that helps them make sense
of the distress s/he is experiencing as an
understandable reaction to significant adversity
and shows how they are (or intend to be)
using personal strengths to make a positive
contribution consistent with their core values
5 Goals for Therapeutic PFA
Create safety by listening
attentively, nonjudgmentally,
and with a focus on core
values/strengths
5 Goals for Therapeutic PFA
Create Calm: the
psychological space is calming
as a respite for reflection and
self-awareness, rather than
reactivity
5 Goals for Therapeutic PFA
Create self- and collective
efficacy: listen carefully and
genuinely validate what they
already are doing to care for
and protect others and self
5 Goals for Therapeutic PFA
Create Connection: the key
is empathic listening to
understand what they are
feeling and thinking that
provides a path forward
5 Goals for Therapeutic PFA
Create hope by helping them
to focus on small steps/wins
that have large meaning
based on their core values
DO confirm their consent to talk via
telehealth, how long the session can last,
and what follow-up options are possible
DON’T rush to make a formal disclosure
and neglect to start by informally
welcoming them to the session by name
DO explain that you’ll listen and help the
worker sort out their thoughts and
feelings as they feel is most helpful
DON’T offer generic reassurance or
coping tactics, false encouragement, false
hooe, or promises that you cannot fulfill
DO carefully assess for current or
imminent major stressors, dangers, or other
safety risks or sources of impairment
DON’T use formal standardized
testing/questionnaires (except as an informal
interview guide) without a relationship
DO listen with a “third ear” to hear their
deeper concerns and hopes as well as the
more evident signs of distress
DON’T just reflect back distress
sympathetically (this tends to be
experienced as superficial and patronizing)
DO help her/him make connections
between specific events that have personal
meaning and strong feelings/thoughts
DON’T make assumptions about what has
happened or why certain events have
particular meaning for this individual
DO explore the impact on their personal
life and how that affects and is affected by
their work life/stressors
DON’T overlook the importance of
personal relationships and activities that
may be negatively impacted or key supports
DO nonjudgmentally acknowledge distress
as understandable in the circumstances and
relate it to their core values
DON’T provide simplistic reassurance or
advice, or attempt to convince them to feel
or think differently
DO creatively build on their strengths,
interests, and talents to brainstorm
modified or alternative coping tactics
DON’T teach generic pre-packaged coping
tactics that are not tailored to their
personality, culture, and preferences
DO identify and reinforce ways they give
to and receive from work support systems
(including supervisors/ees)
DON’T assume that work relationships are
supportive or overlook possible areas of
conflict or tension in their work team
DO identify and reinforce ways they give
to and receive from family/personal
support systems (including faith-based)
DON’T assume that their personal
relationships are supportive and overlook
possible areas of conflict or tension
DO provide links to on-line resources
consistent with their specific goals,
culturally sensitive, and evidence-based
DON’T generically suggest on-line
resources that are not directly relevant to
them or have no evidence base
DO identify and reinforce ways they
are (or want to) engage in practical
self-care, and small steps to doing so
DON’T suggest simplistic “solutions”
or coping tactics that are unrealistic or
that are not tailored to the individual
DO make sure they leave the session with
at least one thought or tool that provides
a sense of a way forward
DON’T end the session without an
integrative conclusion that highlights their
accomplishment(s) in the session
DO establish a practical way for them to
make contact with you again consistent
with professional boundaries
DON’T end the session with a generic
message (e.g., “have a good day”) that
provides no continuity and is superficial
DO use your reflective processing skills and
supports to handle secondary traumatic
stress and countertransference (including
both positive and negative reactions to the
individual and to what they disclose)
DON’T work in isolation—without
support/consultation for your wellness and to
prevent countertransference enactments
Take Home Point 1.
Each session with healthcare worker(s) who
care for COVID-19 patients or is a support
staff interacting with COVID-19 patients is an
opportunity to help them to recognize and
reaffirm their core values, to make sense of
their distress and confusion, and to receive
an authentic message of respect for making
the world a better place in this time of crisis.
Take Home Point 2.
Beyond each individual session or debriefing,
mental health and social work providers can
empower nursing, medical, and allied health
workers by teaching them principles of PFA
that they can take back to their work setting:
• Informally enhancing their communication and
coordination with their work team colleagues
• Formally as peer co-debriefers to front-line
healthcare workers outside their work team